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Health Inspection

Falcon Heights Rehabilitation And Nursing Llc

July 31, 2024 · Colorado Springs, CO · 1795 Monterey Rd
Citations 1
CMS Rating 3/5
Beds 107
Provider ID 065168
Healthcare Facility
Falcon Heights Rehabilitation And Nursing Llc
Colorado Springs, CO  ·  View full profile →
Inspection Summary

FALCON HEIGHTS REHABILITATION AND NURSING LLC in COLORADO SPRINGS, CO — inspection on July 31, 2024.

Found 1 citation. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF555
Minimal harm or or their responsible parties' consent. call physicians did not call her back after leaving multiple messages. He said since Resident #9 was not affected

According to the July 2024 computerized physician

cerebral infarction, bipolar disorder, post-traumatic stress disorder and ataxia (neurological disorder causing lack of coordination and tremors).

The 7/16/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15.

The assessment indicated Resident #35 needed set-up assistance for eating and substantial assistance for personal hygiene and dressing.

B.

Resident observations

On 7/29/24 at 5:48 p.m. a medication cup containing three medication capsules was observed on Resident #35's overbed table.

The resident was sitting in her wheelchair at the table waiting for her supper.

On 7/31/24 at 8:31 a.m. a medication cup containing three medication capsules was observed on Resident #35's overbed table.

The resident said it was her Creon (a medication used to treat insufficient pancreas function) and the night nurse left it for her to take with breakfast. Resident #35 was observed taking the medications without assistance.

C.

Resident interviews

Resident #35 was interviewed on 7/29/24 at 2:44 p.m.

She said she burned her fingers while smoking about a month ago (June 2024). Resident #35 said when she burned her fingers she was smoking a cigarette and was unsupervised.

Resident #35 was interviewed again on 7/31/24 10:52 a.m. Resident #35 said the nurses brought her Creon medication and left it on her table because she wanted it right when her meal came and the nurse was usually in the dining room at that time.

She said sometimes she could take it herself and sometimes the nurse had to come back and help her due to her tremors. Resident #35 said usually stayed in her room until she took the medication.

She said if she left her room before she took the medications, her roommate watched the pills for her.

D.

Record review

The July 2024 CPO included a physician's order, dated 4/2/24, to give Resident #35's Creon to keep at bedside with meals so the resident could take the medication after the first bites of food.

-The order was discontinued on 7/29/24, during the survey.

-A review of Resident #35's electronic medical record (EMR) did not reveal a self-administration assessment was completed for the resident to self-administer the Creon, nor was it indicated on the resident's comprehensive care plan.

065168

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 065168 B.

Wing 07/31/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Falcon Heights Rehabilitation and Nursing LLC 1795 Monterey Rd Colorado Springs, CO 80910

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in COLORADO SPRINGS, CO, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from FALCON HEIGHTS REHABILITATION AND NURSING LLC or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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